What medications can exacerbate Burning Mouth Syndrome (BMS) in a smoker?

Medications That Can Cause or Exacerbate Burning Mouth Syndrome

The most important medications that can cause or worsen BMS are anticholinergic drugs (particularly those causing dry mouth), ACE inhibitors, antiretrovirals, and certain psychotropic medications—with smoking cessation medications like bupropion and varenicline being particularly relevant for smokers attempting to quit. 1

Primary Medication Categories That Cause BMS

Anticholinergic Medications

• Medications causing xerostomia (dry mouth) are the most common pharmacological trigger for BMS, as dry mouth is a key associated symptom that can initiate or worsen burning sensations 1, 2
• Anticholinergic agents like oxybutynin cause significant dry mouth, which can lead to or exacerbate oral burning symptoms 2
• The mechanism involves reduced salivary flow leading to mucosal irritation and altered oral microenvironment 2

Smoking Cessation Medications (Critical for Smokers)

• Bupropion (Zyban), commonly prescribed for smoking cessation, can cause dry mouth as a dose-related adverse effect, potentially triggering or worsening BMS 3
• Varenicline (Chantix) causes nausea as a common side effect, which may indirectly affect oral symptoms 3
• Nicotine replacement therapy (NRT) products can cause local oral irritation, particularly nicotine gum (jaw soreness, mouth ulcers), lozenges (burning sensation in mouth, dry lips), and sublingual tablets 3

Other Psychotropic Medications

• Antidepressants and anxiolytics can cause xerostomia, though some (like gabapentin and amitriptyline) are paradoxically used to treat BMS 1, 4
• The distinction is critical: while these medications treat neuropathic pain in BMS, they can also cause dry mouth as a side effect 1

Cardiovascular Medications

• ACE inhibitors are recognized causes of oral dysesthesia and burning sensations 1
• Antihypertensive medications that cause dry mouth can contribute to BMS symptoms 1

Critical Considerations for Smokers with BMS

For smokers with BMS, the clinical dilemma is significant: smoking itself increases cardiovascular and cancer risk requiring cessation 3, but smoking cessation medications may worsen BMS symptoms through xerostomia 3.

Management Algorithm for Smokers with BMS:

1. Prioritize smoking cessation despite BMS risk because the mortality benefit of quitting smoking far outweighs the quality of life impact of worsened BMS 3

2. Choose smoking cessation medications strategically:

   • Prefer NRT patches over oral formulations (gum, lozenges, sublingual tablets) to minimize direct oral mucosal irritation 3
   • Consider varenicline over bupropion if dry mouth is a primary concern, as nausea (manageable with food) is more common than xerostomia with varenicline 3
   • Avoid nicotine gum and lozenges specifically, as these cause direct oral irritation including mouth ulcers and burning sensations 3

3. Implement aggressive xerostomia management concurrently:

   • Increase hydration and limit caffeine intake 1, 2
   • Use saliva substitutes and moisture-preserving mouth rinses 1, 2
   • Consider systemic sialagogues (pilocarpine or cevimeline) for severe cases 1, 2

4. Monitor and adjust: If BMS worsens significantly on smoking cessation medications, consider switching formulations (e.g., from bupropion to varenicline, or from oral NRT to transdermal) rather than abandoning cessation efforts 3

Common Pitfalls to Avoid

• Do not discontinue necessary cardiovascular medications (like ACE inhibitors) solely for BMS without considering alternative agents first, as cardiovascular mortality risk supersedes BMS quality of life impact 3
• Do not assume all psychotropic medications worsen BMS—gabapentin and amitriptyline are first-line treatments despite potential xerostomia side effects 1, 4, 5
• Do not discourage smoking cessation in BMS patients due to medication concerns; the cancer and cardiovascular mortality benefits are overwhelming 3
• Avoid oral care products containing alcohol or strong flavoring agents, as these exacerbate symptoms regardless of medication use 1

Medication-Induced vs. Primary BMS

Before attributing BMS to medications, exclude other secondary causes including oral candidiasis, hematological disorders, autoimmune conditions, and nutritional deficiencies 1. The diagnostic process requires ruling out these factors before concluding medication is the primary culprit 1.